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Constrained Cups Appear Incapable of Meeting the Demands of Revision THA

  • Symposium: Retrieval Studies
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Failure rates of constrained cups for treating recurrent dislocation in revision THA range from 40% to 100%. Although constrained liners are intended to stabilize the hip by mechanically preventing dislocation, the resulting loss of range of motion may lead to impingement and, ultimately, implant failure.

Questions/purposes

We therefore documented the mechanisms of failure of constrained acetabular cups in revision THA and determined the type and severity of damage (wear, fracture, and impingement) that occurs in situ.

Methods

We retrieved 57 constrained components of four different designs at revision THA and examined for the presence of rim impingement, oxidation, cracks within the liner, backside wear, pitting, scratching, abrasion, burnishing, and the presence of embedded particles. Articular wear was calculated from the volume of the concave articular bearing surface, which was measured using the fluid displacement method.

Results

Failure of the locking ring was responsible for 51% of failures, whereas 28% of revisions were the result of acetabular cup loosening, 6% backside wear, and 22% infection. Impingement damage of the rim of the polyethylene liner was seen in all retrievals with moderate or severe damage in 54%. The average volumetric wear rate of the articular surface was 95 mm3/year.

Conclusions

Failure of the locking liner ring and loosening of the acetabular cup are the primary causes of mechanical failure with constrained liners; polyethylene is an inadequate material for restricting motion of the hip to prevent instability. The durability of these devices is unlikely to improve unless the mechanical demands are modified through increased range of motion leading to less frequent rim impingement.

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Acknowledgments

We thank Dr Kimberley Dwyer, Ms Denise Leon, and Mr Paul Newhouse for their assistance with the statistical analysis of the data and preparation of the manuscript.

Author information

Authors and Affiliations

  1. The Institute of Orthopedic Research and Education, Baylor College of Medicine, 6550 Fannin Street, Suite 2501, Houston, TX, 77030, USA

    Philip C. Noble PhD

  2. The Institute of Orthopedic Research and Education, 6550 Fannin Street, Suite 2501, Houston, TX, 77030, USA

    Salim K. Durrani MD & Molly M. Usrey BS

  3. The Methodist Hospital, Houston, TX, USA

    Philip C. Noble PhD & Kenneth B. Mathis MD

  4. The South West London Elective Orthopaedic Centre, Epsom and St. Helier University Hospitals NHS Trust, Dorking Road, Epsom, KT18 7EG, Surrey, UK

    Nikolaos V. Bardakos MD

  5. Orthopedic Surgery, Weill Cornell Medical College of Cornell University, New York, NY, USA

    Kenneth B. Mathis MD

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  1. Philip C. Noble PhD
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Correspondence to Philip C. Noble PhD.

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Appendix 1: Devices examined in this study

Appendix 1: Devices examined in this study

The constrained cups examined in this study were of four different designs (Fig. 1):

  1. (1)

    The S-ROM cup (DePuy Orthopedics, a Johnson & Johnson Company, Warsaw, IN, USA; formerly Joint Medical Products, Stamford, CT, USA). In this design, the additional constraint is afforded by the presence of an extended polyethylene rim, which, through the presence of six slits, deforms to accept the femoral head. A titanium alloy locking ring is assembled over the rim once the head is reduced to prevent reexpansion and dislocation. The liner is manufactured from conventional UHMWPE with a minimum thickness of 5 mm and fits shells of 48 to 66 mm (28-mm liner) and 54 to 75 mm (32-mm liner) outer diameter [23]. The constraining force of the ring is greater than 600 lbs for the 32-mm liner and 325 lbs for the 28-mm liner [50]. The leveraged torque to disengage the femoral head was 150 inch-lbs [30].

  2. (2)

    The Trilogy Longevity Constrained Liner (Epsilon socket) (Zimmer, Warsaw, IN, USA) was introduced in 2003 and can be locked into any Trilogy cup or cemented into the acetabulum directly. The face of the liner consists of two elevated segments with contiguous cutouts located anterosuperiorly and posteroinferiorly. The cutouts are designed to reduce impingement in full flexion with internal rotation and in extension with external rotation as well as to maximize ROM. All Longevity liners use the highly crosslinked polyethylene (Durasul). Twenty-eight-millimeter, 32-mm, and 36-mm liners are available for implantation with a ROM of 115°, 120°, and 125°, respectively, according to the product data sheet. Proprietary testing determined the lever-out strength is 235 inch-lbs. A titanium alloy constraining ring is mounted on the face of the liner to hold its elevated fingers in a closed position. Pegs on the constraining ring lock into slots on the periphery of the liner with impaction.

  3. (3)

    DePuy Duraloc (DePuy Orthopedics). The UHMWPE (Enduron) liner has a minimum thickness of 6 mm and is compatible with either the Duraloc or Solution acetabular shells [47]. Reducing the femoral head requires 75 lbs of pressure, after which the titanium alloy ring is secured into a circumferential groove on the liner face. The 28-mm diameter liner has a pullout strength of 416 lbs and a lever-out strength of 170 inch-lbs [50].

  4. (4)

    Biomet Freedom Constrained Liner (Biomet Inc, Warsaw, IN, USA), a recent design using compression-molded ArCom polyethylene. The 36-mm femoral head has circumferential flats, which can counteract distractive forces leading to dislocation. Compared with older designs, there is an increased ROM before impingement to 110° and lever-out strength of 198 inch-lbs [50].

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Noble, P.C., Durrani, S.K., Usrey, M.M. et al. Constrained Cups Appear Incapable of Meeting the Demands of Revision THA. Clin Orthop Relat Res 470, 1907–1916 (2012). https://doi.org/10.1007/s11999-011-2212-4

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